Leena Khaitan

Emory University, Atlanta, GA, United States

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Publications (31)167.21 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Endoluminal therapies have emerged as adjuncts for the treatment of gastroesophageal reflux disease (GERD) in select patients. To compare the effectiveness of endoscopic full-thickness plication and endoscopic radiofrequency treatments for patients with GERD. A total of 126 patients who underwent either endoscopic full-thickness plication (FTP) of the gastric cardia or endoscopic radiofrequency (RF) treatment of the esophagogastric junction during a 4-year period were included (68 underwent RF and 58 underwent FTP). Follow-up data was obtained for 51% of patients (mean follow-up, 6 months). Comparison of medication use, symptom scores, and pH values at baseline and follow-up. In the RF group, patients with moderate to severe heartburn decreased from 55% to 22% (P < .01), and proton pump inhibitor (PPI) use decreased from 84% to 50% (P = .01). Decreases were also seen for dysphagia, voice symptoms, and cough. Percentage of time the pH was less than 4 was unchanged. In the FTP group, patients with moderate to severe heartburn decreased from 53% to 43% (P = .3), and PPI use decreased from 95% to 43% (P = .01). Percentage of time the pH was less than 4 decreased from 10.0% to 6.1% (P = .05). Decreases were also seen for regurgitation, voice symptoms, and dysphagia. There was no change in scores for chest pain or asthma in either group. For patients with GERD, RF and FTP both resulted in a decrease in both PPI use and in scores for voice symptoms and dysphagia. In addition, RF resulted in decreased heartburn and cough, while FTP resulted in the most dramatic reduction in regurgitation. Our experience indicates that both procedures are effective, providing symptomatic relief and reduction in PPI use. For patients whose chief complaint is regurgitation, FTP may be the preferred procedure.
    Archives of surgery (Chicago, Ill.: 1960) 01/2009; 144(1):19-24; discussion 24. · 4.32 Impact Factor
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    ABSTRACT: The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes. A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence. A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence. On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.
    Surgical Endoscopy 10/2007; 21(9):1487-91. · 3.43 Impact Factor
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    ABSTRACT: Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery. A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2. A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: "What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?" The second highest-ranked question was: "Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?" Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment. An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.
    Surgical Endoscopy 10/2007; 21(9):1518-25. · 3.43 Impact Factor
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    ABSTRACT: Recurrent reflux following antireflux surgery (ARS) can be difficult to manage, especially in patients who also fail medical management. In these patients, redo ARS remains the only treatment option. Endoscopic radiofrequency energy delivery to the lower esophageal sphincter (the Stretta procedure; Stretta, Curon, Sunnyvale, CA) has been shown to significantly decreased symptom scores and improve quality of life in patients with gastroesophageal reflux disease (GERD). The aim of this study was to evaluate the use of the Stretta procedure in treating patients with recurrent reflux after fundoplication. Between March 2002 and December 2003, eight patients with recurrent reflux following ARS underwent the Stretta procedure. All patients were asked to complete an institutional symptom survey pre-Stretta and at 1, 6, and 12 months after the procedure. Patients rated 7 reflux-related symptoms (heartburn, dysphagia, regurgitation, cough, voice changes/hoarseness, asthma, chest pain) on a 0 (none) to 3 (severe) scale. Data were analyzed using a Wilcoxon matched pairs signed rank test where appropriate. Complete data were obtained for seven of the eight patients, with a median follow-up of 253 days (range, 67-378 days). One patient was lost to follow-up and not included in our analysis. Symptom scores decreased significantly, with six patients noting both improved typical and atypical symptoms. Overall, six patients (85%) were satisfied with their results. Based on this small series, the Stretta procedure significantly reduces subjective symptoms of GERD. The Stretta procedure may serve an important role as an additional management strategy to help manage recurrent GERD after ARS.
    Surgical Endoscopy 08/2007; 21(7):1207-11. · 3.43 Impact Factor
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    ABSTRACT: The use of radiofrequency energy (RFe) treatment at the gastroesophageal junction (GEJ) has been considered an alternative to surgery after fundoplication disruption. It is unknown whether the recommended delivery technique for primary gastroesophageal reflux disease applies to an anatomically altered GEJ following fundoplication. The aim of this study was to determine whether modifications to the standard technique using fluoroscopic guidance more accurately localizes ablation zones compared with standard technique alone. Ten pigs were randomized to either conventional or fluoroscopically guided RFe ablation. All pigs had a laparoscopic Nissen fundoplication that was subsequently disrupted by severing all but the most cranial fundoplication stitch. Conventional RFe delivery included usage of markers located on the Stretta catheter. After labeling the z-line via submucosal contrast injection, fluoroscopic guidance involved using fluoroscopic markers to guide RFe ablation. Ablations were acutely marked, measured, and agreed upon by a panel of three researchers analyzing harvested tissue. Distances from the target zone for each ablation line (e.g., 1 cm was the target zone for line 1) were calculated and analyzed using Mann-Whitney and Fischer's tests. Fluoroscopic guidance was significantly more accurate than the conventional technique (0.2 +/- 0.2 cm vs. 1.8 +/- 0.8 cm, p < 0.0001). Analyzing the individual distances for each of the six ablation lines revealed that all within Group B were closer than Group A (p < 0.01 for all except lines 1 and 2). Overall, the total ablation treatment length for conventionally treated animals was 4.48 +/- 0.7 cm and for those who underwent fluoroscopic guidance it was 2.92 +/- 0.5 cm (p < 0.001). In a porcine model of fundoplication disruption, fluoroscopic guidance improved RFe accuracy.
    Surgical Endoscopy 08/2007; 21(8):1332-7. · 3.43 Impact Factor
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    ABSTRACT: Obesity-related glucose intolerance is a function of hepatic (homeostatic model assessment-insulin resistance [HOMA-IR]) and peripheral insulin resistance (S(i)) and beta-cell dysfunction. We determined relationships between changes in these measures, visceral (VAT) and subcutaneous (SAT) adipose tissue, and systemic adipocytokine biomarkers 1 and 6 months after surgical weight loss. HOMA-IR decreased significantly (-50%) from baseline by 1 month and decreased further (-67%) by 6 months, and S(i) was improved by 6 months (2.3-fold) weight loss. Plasma concentrations of leptin decreased and adiponectin increased significantly by 1 month, and decreases in interleukin-6, C-reactive protein (CRP), and tumor necrosis factor-alpha were observed at 6 months of weight loss. Longitudinal decreases in CRP (r = -0.53, P < 0.05) were associated with increases in S(i), and decreases in HOMA-IR were related to increases in adiponectin (r = -0.37, P < 0.05). Decreases in VAT were more strongly related to increases in adiponectin and decreases in CRP than were changes in general adiposity or SAT. Thus, in severely obese women, specific loss of VAT leads to acute improvements in hepatic insulin sensitivity mediated by increases in adiponectin and in peripheral insulin sensitivity mediated by decreases in CRP.
    Diabetes 03/2007; 56(3):735-42. · 7.90 Impact Factor
  • Gavin French, Leena Khaitan
    Operative Techniques in General Surgery 09/2006; 8(3):119–126.
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    ABSTRACT: The cytokine response to operative trauma may be altered in obesity. Thus, we monitored changes in systemic and adipose tissue content of interleukin 6 (IL-6) and in insulin resistance in nonobese versus severely obese patients before and immediately after abdominal operations. At the beginning and the end of operation, blood samples and biopsies consisting of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were collected from 13 nonobese and 33 severely obese patients. Systemic concentrations of glucose, insulin, and IL-6, as well as adipose tissue content of IL-6, were determined. Plasma IL-6 concentration and adipose tissue content of IL-6 increased, compared with baseline in patients after operation (plasma, 13- and 5.7-fold; VAT, 270- and 210-fold; SAT, 79- and 8.2-fold in severely obese vs nonobese patients, respectively). The increase in IL-6 in plasma and in both VAT and SAT was exaggerated in severely obese patients, compared with nonobese patients. Increases after operation in plasma IL-6 concentrations were correlated positively to the corresponding increases in both SAT and VAT IL-6 content (r = 0.57 and 0.66, respectively). Also, we found a positive correlation between the worsening of insulin resistance and increases in both plasma and SAT IL-6 concentrations (r = 0.40 and 0.51, respectively). Circulating IL-6 concentrations both at baseline and after operation are related strongly to abdominal adipose tissue content of content of IL-6 and are exaggerated in severely obese persons. After operation, worsening of insulin resistance is associated with increasing plasma and adipose tissue content of IL-6.
    Surgery 08/2006; 140(1):50-7. · 3.37 Impact Factor
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    ABSTRACT: This study aimed to determine the utility of a screening colonoscopy program initiated by general surgeons in an academic center. New patients presenting to three general surgeons who met screening colonoscopy indications were asked whether they had undergone colorectal cancer (CRC) screening. The patients who had not undergone CRC screening were offered screening colonoscopies or referred to their gastroenterologists. In the first 9-month period of the program, 200 patients who met the Society of American Gastrointestinal and Endoscopic Surgeons/American Society of Colon and Rectal Surgeons indications for CRC screening were asked whether they had undergone screenings. Only 46% (n = 92) reported any prior appropriate screenings. Of the patients who elected CRC screening by the surgeons, 55 underwent full colonoscopies (2 concurrently with hemorrhoidectomies), and 2 had flexible sigmoidoscopies. As a result of screening, 10 patients (18%) required treatment: 7 had polypectomies, 2 had partial colectomies, and 1 with an indication for surgery deferred treatment. Most of the patients presenting to the general surgeon likely have not had CRC screening, and diligence in making appropriate recommendations should be routine. Colonoscopic findings requiring intervention are not insignificant.
    Surgical Endoscopy 07/2006; 20(6):964-6. · 3.43 Impact Factor
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    ABSTRACT: The addition of a Dor antireflux procedure reduces the risk of pathologic gastroesophageal reflux (GER) by ninefold following laparoscopic Heller myotomy for achalasia. It is not clear, however, how these benefits compare with the increased cost of the fundoplication. The objective of this study was to estimate the cost-effectiveness of Heller myotomy plus Dor fundoplication compared with Heller alone in patients with achalasia. We conducted a cost-utility analysis using the Markov simulation model to examine the two treatment alternatives. The model estimated the total expected costs of each strategy over a 10-year time horizon. Data for the model were derived from our randomized clinical trial. The strategies were compared using the method of incremental cost-effectiveness analysis. The incidence of pathologic GER was 47.6% (10 of 21 patients) in the Heller group and 9.1% (2 of 22 patients) in the Heller plus Dor group using an intention-to-treat analysis (p = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GERD (relative risk 0.11; 95% confidence interval 0.02-0.59; p = 0.01). The cost of surgery was significantly higher for Heller plus Dor than for Heller alone (mean difference $942; p = 0.04), secondary to a longer operating room time (mean difference 40 min; p = 0.01). At a time horizon of 10 years, when proton pump inhibitor (PPI) therapy costs are considered, the cost-utility analysis demonstrates that Heller plus Dor surgery is associated with a total cost of $6,861 per patient and a quality-adjusted life expectancy of 9.9 years, whereas Heller-alone surgery is associated with a cost of $9,541 per patient and a quality-adjusted life expectancy of 9.5 years. In achalasia patients, Heller myotomy plus Dor fundoplication is preferred to Heller alone because it is both more effective in preventing postoperative GERD and more cost-effective at a time horizon of 10 years.
    Surgical Endoscopy 04/2006; 20(3):389-93. · 3.43 Impact Factor
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    ABSTRACT: In 1999, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) introduced the SAGES Outcomes Initiative as a way for its members to track their own outcomes. It contains perioperative and postoperative data on nearly 20,000 operations. This report provides a descriptive analysis of the groin hernia database. The SAGES Outcomes Initiative database was accessed for all groin hernia cases from September 1999 to February 2005. The data from the preoperative, intraoperative, and postoperative entries were summarized. These data are purely descriptive and no statistical analysis was done. The hernia registry contains 1,607 entries, with 1,070 follow-up entries. Males comprised 85% of patients, 63% were employed, 62% had at least one comorbidity, with 84% ASA class I or II. Primary, unilateral hernia accounted for 86% of cases, whereas 14% were recurrent, 11% bilateral, 6% incarcerated, and 3% required emergency repair. The operating surgeon was the attending surgeon in 83% of cases. Anesthetic techniques were general anesthesia in 74% of cases, regional in 7%, and local in 34%, with only 16% of cases local only. Most patients had symptomatic hernias and symptoms were improved in more than 95% of patients. Most repairs were open, although 45% were endoscopic. The most frequently cited postoperative event was significant bruising (6%), with more than 99% of complications being class I or II. More than 95% of patients were able to return to work by the first postoperative visit. Patients who underwent endoscopic repair were reported to have fewer days of narcotic use than patients undergoing open repairs (0 vs 3). First analysis of the SAGES Outcomes Initiative groin hernia database demonstrates that (a) this is one of the largest prospective; voluntary hernia registries; (b) missing data are infrequent; and (c) the data are similar to published data from national, mandatory registries and randomized trials. Although the SAGES Outcomes Initiative is a voluntary registry, initially designed for surgeon self-assessment, and it therefore has the potential for methodological concerns inherent to voluntary registries, the findings from this first analysis are encouraging. Efforts are ongoing to simplify data entry (PDA), refine data parameters, increase surgeon participation, and determine the role of data audit and thereby the potential for clinical research.
    Surgical Endoscopy 03/2006; 20(2):191-8. · 3.43 Impact Factor
  • Leena Khaitan, C Daniel Smith
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    ABSTRACT: Over 60% of the American population is either overweight or obese. Conventional treatment through decreased caloric intake and increased physical activity has been minimally effective in achieving sustained weight loss. Pharmacotherapies are effective in inducing some weight loss; however, lost weight is regained once the medications are stopped. Surgical weight loss is the only treatment that has been demonstrated to achieve durable weight loss, with sustained weight loss for at least 14 years and improvements in or complete resolution of associated comorbidities and improved quality of life. Based on the National Institutes of Health 1991 Consensus Conference guidelines, 16 million Americans are currently potential candidates for weight loss surgery. Although this is an effective treatment for appropriate candidates in the short term, education on nutrition and increased physical activity is more likely to be effective over the long term. One hopes that current research efforts in obesity and public awareness will lead to a decrease in the prevalence of this disease.
    Current Gastroenterology Reports 01/2006; 7(6):451-4.
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    ABSTRACT: The production of inflammatory mediators by abdominal adipose tissue may link obesity and insulin resistance. We determined the influence of systemic levels of interleukin-6 and C-reactive protein on insulin sensitivity after weight loss via Roux-en-Y gastric bypass surgery. Severely obese individuals (n = 15) were evaluated at baseline and at 6 months after surgery. Insulin sensitivity was determined by frequently sampled intravenous glucose tolerance testing at the same time points. Visceral and subcutaneous adipose tissue volumes were quantified by computed tomography. Interleukin-6 and C-reactive protein were measured by enzyme-linked immunoassay in plasma and in adipose tissue biopsies. Correlation analysis was used to determine associations between insulin sensitivity and other outcome variables. Significance was set at P < 0.05. Plasma interleukin-6 concentrations were significantly correlated to the IL-6 content of subcutaneous adipose tissue (r = 0.71). At 6 months postsurgery, subcutaneous and visceral adipose tissue volumes were significantly reduced (34.7% and 44.1%, respectively) and insulin sensitivity had improved by 160.9%. Significant longitudinal correlations were found between insulin sensitivity and plasma C-reactive protein (r = -0.61), but not plasma interleukin-6 at 6 months. These findings offer insights that link obesity and insulin resistance via the activity of inflammatory mediators.
    Journal of Gastrointestinal Surgery 11/2005; 9(8):1119-26; discussion 1127-8. · 2.36 Impact Factor
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    ABSTRACT: Reoperative bariatric surgery is required in 10 per cent to 20 per cent of patients secondary to weight regain or complications of the previous procedure. This study evaluates the feasibility of performing the revision procedure laparoscopically. A retrospective review of all patients undergoing revision of a previous weight loss procedure between October 1998 and November 2003 was conducted. Demographics, indications for surgery, operative findings, and complications were reviewed. Thirty-nine revisions were performed in 37 patients. Indications for revision were failure to lose weight (22), gastric outlet stricture (10), refractory gastroesophageal reflux (GERD) (6), and blind loop syndrome (1). All 39 procedures were revised to Roux-en-Y gastric bypass (RYGBP), with 18 open revisions (OR) and 21 laparoscopic revisions (LR). Ten of the 21 LR (48%) were converted to an open procedure due to adhesions or unclear anatomy. Early complications requiring operation were noted in five procedures (two OR, three LR). Nine patients (seven OR, two LR) required surgery at least 3 months following their revision. One patient died (LR). The difference in body mass index (kg/m2) (BMI) pre- and post-op was 43.3+/-9.9 versus 37.4+/-9.2, P = 0.01 (follow-up 5 months), but no significant BMI differences between LR and OR patients were seen. Revisional bariatric surgery is associated with more complications requiring surgery early in the laparoscopic population versus more late complications in those approached open. Revisional bariatric surgery can be approached laparoscopically and with acceptable morbidity comparable to patients whose revision is approached open.
    The American surgeon 02/2005; 71(1):6-10; discussion 10-2. · 0.92 Impact Factor
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    ABSTRACT: We sought to determine the impact of the addition of Dor fundoplication on the incidence of postoperative gastroesophageal reflux (GER) after Heller myotomy. Based only on case series, many surgeons believe that an antireflux procedure should be added to the Heller myotomy. However, no prospective randomized data support this approach. In this prospective, randomized, double-blind, institutional review board-approved clinical trial, patients with achalasia were assigned to undergo Heller myotomy or Heller myotomy plus Dor fundoplication. Patients were studied via 24-hour pH study and manometry at 6 months postoperatively. Pathologic GER was defined as distal esophageal time acid exposure time greater than 4.2% per 24-hour period. The outcome variables were analyzed on an intention-to-treat basis. Forty-three patients were enrolled. There were no differences in the baseline characteristics between study groups. Pathologic GER occurred in 10 of 21 patients (47.6%) after Heller and in 2 of 22 patients (9.1%) after Heller plus Dor (P = 0.005). Heller plus Dor was associated with a significant reduction in the risk of GER (relative risk 0.11; 95% confidence interval 0.02-0.59; P = 0.01). Median distal esophageal acid exposure time was lower in the Heller plus Dor (0.4%; range, 0-16.7) compared with the Heller group (4.9%; range, 0.1-43.6; P = 0.001). No significant difference in surgical outcome between the 2 techniques with respect to postoperative lower-esophageal sphincter pressure or postoperative dysphagia score was observed. Heller Myotomy plus Dor Fundoplication was superior to Heller myotomy alone in regard to the incidence of postoperative GER.
    Annals of Surgery 10/2004; 240(3):405-12; discussion 412-5. · 6.33 Impact Factor
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    ABSTRACT: Patients who undergo surgical treatment for gastroesophageal reflux disease (GERD) will use fewer health care resources than those who continue to be treated medically during the same follow-up period. Matched cohort study of patients with a diagnosis of GERD receiving surgical therapy or medical therapy. Tennessee Medicaid (TennCare) program from 1996 through 2000. Population-based sample of 7635 TennCare enrollees with a diagnosis of GERD served as the underlying population. Of these, 111 surgical patients who underwent fundoplication in 1996 met inclusion criteria. The 200 patients in the medically treated cohort were randomly matched to patients in the surgical cohort by demographic characteristics and previous use of acid-suppressing drugs. The surgical group all underwent fundoplication in 1996. The medical group was treated without fundoplication. Health care utilization (medication use, outpatient visits, hospitalizations, and diagnostic studies) for each cohort through December 2000. In the 4-year follow-up period, the surgical group had fewer GERD-related outpatient physician visits (5.5 +/- 6.9 visits vs 6.7 +/- 6.1 visits; P =.10). Utilization of other types of outpatient and inpatient care was similar. During each year of follow-up, the proportion of persons using GERD medication was lower in the surgical group. (0.67 vs 0.93 in year 1, 0.67 vs 0.91 in year 2, 0.72 vs 0.85 in year 3, and 0.74 vs 0.90 in year 4). The utilization of health care resources in patients treated surgically for GERD is associated with a modest decrease in the use of GERD-related medications and GERD-related visits.
    Archives of Surgery 01/2004; 138(12):1356-61. · 4.10 Impact Factor
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    ABSTRACT: A prospective study was designed to characterize patients with typical and extraesophageal reflux (EER) symptoms and seek predictive patterns for each group. Fifteen subjects without symptoms, 16 patients with symptomatic gastroesophageal reflux disease (GERD), and 37 patients with symptomatic EER were evaluated with outcomes tools, videolaryngoscopy, and 24-hour triple-probe pH monitoring. Higher symptom scores, Voice Handicap Index scores, and Gastrointestinal Symptom Rating Scale scores, as well as similarly decreased quality of life as measured by the Short Form 36, were noted among the two symptomatic groups. Patients with clinically diagnosed EER were more likely to have multiple abnormalities on laryngoscopy. There was a trend toward more pharyngeal reflux episodes in EER patients (6.9 +/- 8.9) as compared to GERD patients (6.0 +/- 9) and asymptomatic subjects (1.1 +/- 1.9). On the basis of the pH monitoring of asymptomatic subjects, we define pathological pharyngeal reflux as more than 5 episodes in 24 hours. Pharyngeal acid exposure is more common in patients presumed to have EER, but some pharyngeal reflux does occur in asymptomatic subjects. Neither symptom scores nor videolaryngoscopic findings were predictive of pathological EER as indicated by pH monitoring.
    The Annals of otology, rhinology, and laryngology 11/2003; 112(10):859-65. · 1.21 Impact Factor
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    ABSTRACT: Although much has been written about the results and patient satisfaction with fundoplication for the treatment of gastroesophageal reflux disease, the reports have focused primarily on surgical successes. With the growing number of fundoplications being performed, more patients are requiring reoperation because of recurrent symptoms or side effects. Reports of success rates for reoperation are available, but information regarding patient satisfaction is limited. All the patients undergoing fundoplication at our institution were sent short-form health surveys (SF-12), Gastroesophageal reflux disease-specific quality-of-life questionnaires (QOLRAD), and queries regarding long-term satisfaction. Between November 1992 and July 2000, 221 patients (198 primary and 23 redo) underwent fundoplication. There were 19 open cases (3 primary and 16 redo). In the primary group, 173 patients underwent Nissen, 23 underwent Toupet, and 2 underwent Collis fundoplications. In the redo group, 12 patients underwent Nissen, 9 underwent Toupet, 1 underwent Collis, and l underwent Belsey fundoplications. Follow-up surveys were completed for 130 patients (112 primary and 18 redo) at a mean of 32.6 months (range, 0.8-98 months). In the primary group, 87% of the patients were satisfied with their operation, as compared with 75% in the redo group. There was a trend toward higher SF-12 mental scores (46 +/- 12 vs 40 +/- 14; p = 0.07) and QOLRAD scores (6.2 +/- 1.3 vs 5.2 +/- 2.0; p = 0.07) in the primary fundoplication group. There was a significant difference in the SF-12 physical scores between the groups (32 +/- 13 for the primary group vs 18.5 +/- 11 for the redo group; p = 0.0002). Additionally, 61% of the patients in the redo group were again using antireflux medications, whereas only 24% of the patients in the primary group were using medications again. Gastroesophageal reflux disease symptom scores and quality-of-life scores for patients undergoing redo fundoplication are lower than the scores of patients having primary fundoplication. Quality of life is similar between primary and redo fundoplication patients in the mental component. However, redo patients do not do as well physically more than 2 years after surgery.
    Surgical Endoscopy 08/2003; 17(7):1042-5. · 3.43 Impact Factor
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    ABSTRACT: To compare the short-term results of the radiofrequency treatment of the gastroesophageal junction known as the Stretta procedure versus laparoscopic fundoplication (LF) in patients with gastroesophageal reflux disease (GERD). The Stretta procedure has been shown to be safe, well tolerated, and highly effective in the treatment of GERD. All patients presenting to Vanderbilt University Medical Center for surgical evaluation of GERD between August 2000 and March 2002 were prospectively evaluated under an IRB-approved protocol. All patients underwent esophageal motility testing and endoscopy that documented GERD preoperatively, either by a positive 24-hour pH study or biopsy-proven esophagitis. Patients were offered the Stretta procedure if they had documented GERD and did not have a hiatal hernia larger than 2 cm, LES pressure less than 8 mmHg, or Barrett's esophagus. Patients with larger hiatal hernias, LES pressure less than 8 mmHg, or Barrett's were offered LF. All patients were studied pre- and postoperatively with validated GERD-specific quality-of-life questionnaires (QOLRAD) and short-form health surveys (SF-12). Current medication use and satisfaction with the procedure was also obtained. Results are reported as mean +/- SEM. Seventy-five patients (age 49 +/- 14 years, 44% male, 56% female) underwent LF and 65 patients (age 46 +/- 12 years, 42%, 58% female) underwent the Stretta procedure. Preoperative esophageal acid exposure time was higher in the LF group. Preoperative LES pressure was higher in the Stretta group. In the LF group, 41% had large hiatal hernias (>2 cm), 8 patients required Collis gastroplasty, 6 had Barrett's esophagus, and 10 had undergone previous fundoplication. At 6 months, the QOLRAD and SF-12 scores were significantly improved within both groups. There was an equal magnitude of improvement between pre- and postoperative QOLRAD and SF-12 scores between Stretta and LF patients. Fifty-eight percent of Stretta patients were off proton pump inhibitors, and an additional 31% had reduced their dose significantly; 97% of LF patients were off PPIs. Twenty-two Stretta patients returned for 24-hour pH testing at a mean of 7.2 +/- 0.5 months, and there was a significant reduction in esophageal acid exposure time. Both groups were highly satisfied with their procedure. The addition of a less invasive, endoscopic treatment for GERD to the surgical algorithm has allowed the authors to stratify the management of GERD patients to treatment with either Stretta or LF according to size of hiatal hernia, LES pressure, Barrett's esophagus, and significant pulmonary symptoms. Patients undergoing Stretta are highly satisfied and have improved GERD symptoms and quality of life comparable to LF. The Stretta procedure is an effective alternative to LF in well-selected patients.
    Annals of Surgery 05/2003; 237(5):638-47; discussion 648-9. · 6.33 Impact Factor
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    ABSTRACT: The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Outcomes Initiative established a national database in 1999. The goal was to provide a vehicle whereby surgeons could accumulate meaningful data about their surgical activity and procedure outcomes. Through a secure Internet site, participants entered core data at the time of operation on all patients undergoing any laparoscopic or open procedure. Procedure-specific data was accumulated for cholecystectomy, inguinal hernia, and fundoplication. A second data set was collected at the time of follow-up evaluation. Individual data and a summary of national data were available through the Web site for contemporaneous review. Between May 1999 and December 2001, 4,100 cases were entered by 73 surgeons, including data for 1070 cholecystectomies, 1,070 antireflux procedures, and 300 hernias. The remaining cases encompassed all other procedures. Perioperative and follow-up data showed many interesting findings. For example, 30% of cholecystectomies were first-assisted by a nonphysician. The rate of conversion from laparoscopic cholecystectomy to open surgery was 3%. In the gastroesophageal reflex disease (GERD) report on fundoplications, 21% of the patients had a previous fundoplication. This report contains a summary of the data collected during this period in the national database. The SAGES Outcomes Initiative allows surgeons to be involved in data collection about their practice. It provides data on the general practice of surgery, which are more useful for setting benchmarks than published data from the surgical elite.
    Surgical Endoscopy 04/2003; 17(3):365-70. · 3.43 Impact Factor